History and Examination

History

Pain in the groin, medial thigh and greater trochanter radiating to thigh and knee at rest and/or after activity or isolated knee pain condition having an impact on occupation, daily activity and sports (e.g. decrease in walking distance, disability in negotiating stairs and performing pedicure), duration and onset, aggravating and relieving factors, Perthes, details of previous surgery and with who.

Isolated pain over the greater trochanter settles in 64% of patients after one year and 71% after five years.

Examination

Examine the hip for tenderness and irritability on movement.

Differential Diagnoses

• Osteoarthritis
• Femoroacetabular impingement (FAI)
• Trochanteric pain

Emergency referral to Orthopaedics telephone on call team for the following symptoms:

• Unable to walk
• Trauma
• Unable to move hip
• Septic/unwell
• Systemic symptoms
• Signs of infection
• Known primary malignancy
• Raised inflammatory markers
• Sudden deterioration of chronic hip pain
• Hip fracture
• Avascular necrosis/osteonecrosis
• Pathological fracture

• A plain A-P radiograph of the pelvis may be requested to confirm the diagnosis after history and examination if the patient is older than 50 years of age OR is younger than this if OA is suspected
• No further imaging (e.g. MRI or bone scan) is appropriate before referral
• If inflammatory diagnosis is suspected the patient will need FBC/CRP/ Rheumatoid factor
• If a reactive cause is considered chlamydia testing should also be added

Management - offer to all people

Mild symptoms

• offer verbal and written information about condition
• offer information to achieve weight loss if people are overweight or obese (BMI greater than 30) as a core treatment.
• advise to carry out local muscle strengthening and general aerobic exercise as a core treatment
• use of shared decision making tools
• suggest oral simple analgesia and anti-inflammatory medication
• assess need for aids and devices (refer to occupational therapy or physiotherapy) including instruction in using a walking aid.
• prescribe supervised and evidence based physical therapies - refer to Local Physiotherapy Service

Moderate symptoms:

• as above, and
• add NSAIDs (see section 10.1 Drugs used in rheumatic diseases and gout) or stronger analgesics (see section 4.7 Analgesics)
• those assessed to be unsuitable for surgery consider referral for image guided intra-articular steroids, beneficial for between 3 weeks and 3 months.

Referral Criteria

Refer if persistent pain and disability has not responded to up to 12 weeks of evidence based non-surgical treatments, this time to include any manual therapy (including physiotherapy) received in primary care (British Association orthopaedics commissioning guide 2013 ).

All patients with hip pain will be expected to have had a recent course of physiotherapy prior to onward referral unless evidence can be provided that this is not necessary. Unless it is clearly stated in the referral, these maybe returned to the referrer.

Details of conservative treatment including physiotherapy & analgesia should be included in the referral.

DRSS will default to ESP service unless:

• Under 16
• Recent Surgery same joint less than 6/12
• Metal Work in situ in the area
• Inflammatory Arthritis
• Suspected serious pathology
• Ultra sound guided injection
• If addressed to named ESP but inappropriate for ESP- e-mail the named ESP to check
• leaking wound/possible infections

Or: osteoarthritis (the osteoarthritis criteria only applies for moderate to severe osteoarthritis)

+ Xray evidence

Should also meet all of the following criteria

+ Failed conservative management

+ Wants surgery

+ Fit for surgery

(Mild-Moderate can usually go through to an ESP.)

Please note primary care is requested to follow In Shape for Surgery best practice which can be seen here.

Referral Instructions

Emergency referral to secondary care

• hip pain associated with systemic symptoms, signs of infection, known primary malignancy, severe muscle spasm, sudden inability to bear any weight, history of a fall
• Ring on-call team via switchboard 01752 202082

Immediate referral to secondary care

• severe pain unresponsive to analgesia and persistent loss of function affecting employment

Referral to Orthopaedics

• OA on x-ray and severe pain
• Previous revision

Referral to Rheumatology

• If inflammatory cause

Referral to MSK Interface service (OCAS) (unless under 16 and/or failed significant physiotherapy))

• OA and under 40
• FAI on x-ray with symptoms
• Suspected labral pathology
• Young complex hips

Referral to MSK interface service (OCAS)

• Lat hip pain
• Failed injection
• Soft tissue of unknown cause
• Review of less severe OA hip for referral to conservative management 

Referral to Orthopaedics via e-Referral Service

• Priority: Routine/ Urgent
• Specialty: Orthopaedics
• Clinic type: Hip
• Service: DRSS-Western-Orthopaedics-Hip- NHS Devon-15N

Referral form

DRSS referral form

Patient Information

Patient Information for pain arising from the hip in adults

Hip joint replacements

Hip replacement

NICE OA Guideline

Pathway Group

This guideline has been signed off by the East Cornwall Locality on behalf of NHS Devon.

Publication date: April 2015

Review date: March 2017